=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033929047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAFAEL ILAGAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2025
-----------------------------------------------------
Last Update Date | 01/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 461 2ND ST APT C130
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94107-4118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-510-2865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 461 2ND ST APT C130
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94107-4118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-510-2865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 95032904
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------